Emergency Medicine News:
Wiler, Jennifer L. MD, MBA
Dr. Wiler is an assistant professor of emergency medicine and the vice chair of the department of emergency medicine at the University of Colorado School of Medicine. Read all of Dr. Wiler's past columns at http://bit.ly/WilerConsult.
A demented 75-year-old woman is found by family after a reported mechanical fall in her home. She complains of buttocks, hip, and left knee pain. The photo shows the results of her radiograph.
What is the diagnosis, and how is it treated?
Diagnosis: Intertrochanteric Femur Fracture
The strength of the femur has been compared with concrete, but the lateral-angular protrusion of head of the femur via the short neck attachment to the shaft of the femur makes this area particularly weak and prone to breaking. Fractures between the lateral bony prominence (greater trochanter where hip extensors and abductors attach) and the smaller medial bony prominence (lesser trochanter which hip flexors attach) are called intertrochanteric fractures. Fractures that occur below the trochanters are called subtrochanteric versus those above, which are called femoral neck fractures.
Intertrochanteric fractures occur most commonly in women (Am J Epidemiol 1996;143:677), with white females being affected most often. The clinical presentation of intertrochanteric fractures depends on whether an associated dislocation is present. The classic clinical presentation of intertrochanteric fractures is, however, a shortened externally rotated lower limb. It typically is associated with pain, swelling, and ecchymosis to the hip or groin area. Care should be taken to rule out other injuries because this injury is typically related to blunt force trauma. The neurovascular status of the limb should also be noted and any signs of compromise investigated. Hip fractures can be associated with as much as 1.5 L of blood loss, resulting in hemorrhagic shock, because of the dense surrounding vascular beds and close association of the femoral vessels. The most common mechanism of this injury is a fall in an elderly person, and care should be taken to identify any acute precipitants of a fall.
The diagnosis of intertrochanteric fractures is primarily via radiograph, but studies have found a false-negative rate of radiographs for hip fractures of three to four percent. (Acad Emerg Med 2005;12:366; J Emerg Med 2009;37:144.) CT, MRI, or bone scan should be performed to rule out an acute fracture if a fracture is suspected clinically. MRI has been shown to be 100% sensitive in identifying hip fractures. (AJR Am J Roentgenol 2010;194:1054.)
Treating intertrochanteric fractures is primarily operative via open reduction and internal fixation, and urgent orthopedic evaluation is warranted. (J Am Acad Orthop Surg 2008;16:665; Injury 2013;44:1904.) Immobilization and traction were alternative therapies in the past, but this is no longer recommended because of complications related to prolonged immobilization (pulmonary embolism, decubitus ulcers, pneumonia, etc.). It may, however, be an option for patients with limited pre-injury mobility and conservative care goals.
Despite appropriate treatment, the prognosis of hip fractures is fairly poor, with an in-hospital mortality rate as high as 15 percent (J Am Geriatr Soc 2013;61:2248; Can J Surg 2010;53:294) and the one-year mortality rate as high as 35 percent. (Arch Intern Med 2011;171:1831.) Risk factors include shock, dialysis, obesity, and time to surgery. (Arch Orthop Trauma Surg 2014 Feb 26.)
This patient was diagnosed with a slightly comminuted intertrochanteric fracture of the left femur. She had an ORIF performed on hospital day two (photo). Two days later, she was found to large a large right-sided pulmonary embolism. Goals of care were discussed with her family, who requested transition to hospice.
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